Report of Medical / Mental Health Condition
For Academic Accommodations
Humber Disability Services
Attention Health Care Practitioner: This form will be used as part of the criteria to determine the student’s
eligibility to receive academic accommodations and support services at Humber College Institute of
Technology and Advanced Learning or the University of Guelph-Humber. The diagnosis must accurately
represent the student’s disability.
Confidentiality: Collection, use and disclosure of this information is subject to all applicable privacy legislation.
To Be Completed by the Student:
Name:___________________________________ Student # _____________ Date of Birth: ____________
(First)
(Last)
Day / Month / Year
Address: ________________________________________________________________________________
(Street and Number)
(City, Province)
(Postal Code)
Phone 1: _______-_______-__________ Phone 2: _______-_______-__________
Email: ______________________________________________________________
Student Consent for Release of Information:
I, ______________________________, hereby authorize the health care practitioner to provide the following
information to Disability Services and, if required, to supply additional information regarding my disability
related services. I also authorize Disability Services and Humber College Institute of Technology and
Advanced Learning / the University of Guelph-Humber to contact the health care practitioner to discuss the
provision of accommodations. I understand that it is my responsibility to pay for the cost of this documentation,
if required.
______________________________________
Student Signature
______________________________________
Date
To Be Completed by the Regulated Health Care Practitioner:
PLEASE PRINT CLEARLY
Avoid the use of terms such as “suggests” or “indicates”. If the criteria for a diagnostic disability are not
present, that must be stated in the report. Multiple diagnoses or comorbid conditions should be included. If
Mental Health - note DSM diagnosis; Vision - note Visual Acuity; Hearing – identify severity.
Specific Diagnosis:
Primary: ____________________ Secondary: ____________________ Other: ____________________
Date of onset of primary condition:
Day _____ Month _____ Year _______
Is the primary disability:
 Permanent (expected to remain with patient for their expected natural life)
 Characterized by fluctuations in functioning
 Progressive
 Chronic
 Temporary: Anticipated date of recovery Day _____ Month _____ Year _______
Please complete other side
Functional Impact:
Please indicate issues that the student may face as a result of their disability/disorder and/or medication as a
student in an educational setting. If more space is required, please attach.





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Concentration/Attention/Focus _____________________________________________________________
Memory _______________________________________________________________________________
Mobility _______________________________________________________________________________
Fatigue _______________________________________________________________________________
Chronic pain ___________________________________________________________________________
Learning difficulties ______________________________________________________________________
Social/Emotional difficulties _______________________________________________________________
Other _________________________________________________________________________________
Treatment Plan:
Has a treatment been recommended?
Is this student receiving this treatment?
Medications:
Brand or Generic
Names
 Psychotherapy – note frequency:
 Other – please specify:
 Yes  No
If more space is required, please attach.
Dosage and
Frequency
Classification
Adverse effect(s) student currently
experiencing that impacts education
Do you consider this person in stable condition and capable of managing normal academic stress?
 Yes
 No - please comment:
Will you be monitoring this person regularly while s/he attends college/university?
 Yes
 No
Verification by Practitioner:
I certify that this person has been a regular patient of mine for:  10+ years
 5-10 years
 2-5 years
 Less than 2 years  Walk-In / First Visit
Last date of clinical assessment:
Day _____ Month _____ Year _______
Practitioner’s Name: _________________________________________
(Please Print)
Date: ____________________
________________________________________ ________________________________________
SIGNATURE
PROFESSIONAL DESIGNATION
Address: ________________________________________________________________________________
(Street and Number)
Business Stamp:
(City, Province)
(Postal Code)
____________________
TELEPHONE #
____________________
FAX #
Please address questions or concerns to Disability Services:
North Campus 416-675-5090 Lakeshore Campus 416-675-6622 ext.3331
Revised September 2013